Transcript Genitourinary Surgery - JATC Surgical Technology

Genitourinary Surgery
Anatomy
Suprarenal (adrenal) Glands
Adrenal glands-sit on the
superior and medial portion
of the kidneys.
Endocrine glands with a cortex
and medulla.
-Cortex- secretes steroidtype hormones essential to
the control of fluid and
electrolyte balance.
-Medulla- secretes
epinephrine and
norepinephrine.
-Enclosed within the
Gerota’s fascia
Kidneys: Filter waste




Left kidney is larger than the right.
Right kidney is lower than the left.
Located in the retroperitoneal space.
Nephrons are the functional unit of the kidney.
 There are more than 1 million nephrons.
 Two types- juxtamedullary (deep) and cortical (shallow) nephrons.
2 Basic Units of the Nephron
 Renal corpuscles
 Consist of a network of capillaries
 Called the glomerulus, and Bowman’s capsule
 Lie in the cortex of the kidney.
 Create a filter through which many substances
must pass.
 Renal tubules
 Consists of 3 units
 Proximal convoluted tubule
 Loop of Henle
 Distal convoluted tubule.
Ureters
 Conduct urine from the kidney
to the bladder
 Have thick-walled muscular
tubes with small lumen.
 Terminates by running
obliquely through the wall of
the bladder for about 1.5 cm. It
allows the bladder to prevent
reflux through muscular
contraction upon the ureter.
 The pelvic ureter in the female
relates to other structures in
such a way as to create
several surgical problems.
Urinary Bladder
 Urine collects in the bladder
 Lies in the anterior half of the pelvis.
 Lined with a mucous membrane that is wrinkled when the bladder is




not distended.
Openings to the ureters are approximately 3 cm apart.
Trigone-triangular area connecting ureters and urethra
Male bladder lies on and is attached to the base of the prostate
gland.
Detrusor Muscle
Male Reproductive System
Penis and Male Urethra
 Cylindrical structure composed of three cylindrical masses of
cavernous tissue.
 Two Corpora Cavernosa
 Corpus Spongiosum Penis
 Lies in the midline below these two structures.
 Expands distally forming the glans penis.
 Urethra passes through here and opens to the exterior via a slit like opening, the
urethral orifice or meatus.
 The skin covering the penis is thin, hairless, and somewhat dark.
 The prepuce (foreskin) resembles a mucous membrane and covers the
glans penis.
 Urethra- passes through the prostate gland
 Prostatic section of the urethra passes through the prostate with a gentle
forward curve.
 Ejaculatory duct opens on each side of a urethral structure called the
prostate utricle.
 Spongy section of the urethra is about 15 cm long.
Female Urethra
 Only 4 cm long.
 Passes in front of the lower half of the
vagina.
 Voluntary sphincter muscle surrounds the
female urethra.
 Some of these muscle fibers help form the
urethrovaginal sphincter.
 Skene’s glands provide lubrication.
Testes
 Paired structures
contained in the scrotum
 Tunica Vaginalis-interior
lining of the scrotum
 Tunica albuginea-thick
external connective tissue
covering the testes
 800 seminiferous tubles
which connect to the
epididymis
Ductus Deferens (Vas Deferens)
 Arises from the




epididymis
45 cm long
Center portion of the
spermatic cord
Joins the seminal vesicle
distally to form the
ejaculatory duct
Ejaculatory Ducts-lie
within the prostate where
they enter the prostatic
urethra
Prostate Gland
 Accessory gland (seminal)
 Lies at the base of the bladder
 Urethra runs through it
 Entry site for ejaculatory ducts
 Enclosed by a capsule
Pathology
Cushing’s Syndrome
 Over production of cortisol by
adrenal cortex caused by
 Over production of ACTH
(adrenocorticotropic hormone) by
the pituitary gland (80%)
 Or a tumor of the adrenal cortex
(20%)
 Benign or malignant
 Diagnosis
 Urine and blood tests
 CT or MRI of brain
 Adrenal ultrasound
 Symptoms
 Central body obesity
 Glucose intolerance
 Hypertension
 Hirsutism (hairiness)
 Osteoporosis
 Kidney stone formation
 Emotional instability
 Menstrual irregularity
 Treatment
 Surgical removal of pituitary
tumors
 Radiation
 Benign adrenal tumors are
removed endoscopically (general
surgeon)
 Malignant adrenal tumors
removed in open procedure
Adrenal Insufficiency
(Addison’s Disease)
 Adrenal glands fail to
secrete hormones
necessary to maintain
fluid balance and blood
pressure, or they inhibit
the stress response
 May be triggered by
stress
 Infection
 Surgery
 Trauma
 May be a complication of
TB or AIDS
 Symptoms







Weight loss
Weakness and fatigue
GI disturbances
Low blood pressure
Darkening of skin
Hair loss
Dramatic mood and
behavior changes
 Treatment is medical
 Hormone replacement
therapy (corticosteroids)
Pheochromocytoma
 Tumor of the medulla of the adrenal gland
 Over production of adrenalin
 Can be deadly
 Symptoms








Severe headaches
Excess sweating
Tachycardia-palpitations
Anxiety
Tremor
Pain in the epigastric region
Weight loss
Heat intolerance
 Treatment-surgery
 Most tumors are small so are removed endoscopically
Pathology of the
Urinary System
Bladder
 Urinary incontinence
 Cystitis
 Calculi
 Urinary reflux
 Neurogenic bladder
 Trauma
 Straddle Injuries
 Cancer
Bladder Tumors
 Symptom-hematuria
 Benign or malignant
 Benign (papillomas) occur only in young adults
 Cystoscope to diagnose and tumor is removed
transurethrally
 Malignant arise from epithelial lining-men over 50
 Mushroom shaped with a stalk
 For bladder wall invasion partial or total cystectomy may be
required with rerouting of ureters
 Chemotherapy and radiation
 Single or multiple
Urinary Calculi
 Stones-small solid particles
 Imbedded or travel and obstruct
 Symptoms
 Painful urination
 Frequent urination
 Passage of small amounts of
urine
 Flank pain
 Nausea and vomiting
 Urinary tract infection (UTI)
 Hematuria
 50% recurrence
 Chemical types
 Calcium-(75%) diet or
hyperparathyroidism
 Struvite-(15%) magnesium
ammonium phosphate from
chronic UTI
 pH higher than 7.0
 Uric acid-(6%) gout
 pH less than 5.5
 Cystine-metabolic defect of renal
tubules
 Failure to reabsorb certain amino
acids
 Treatment
 Spontaneous passage
 Surgical
 Extracorporeal shock wave
lithotripsy
 Cystoscopicureteroscopicnephros
copic
 Percutaneous
 Open
Kidney Disorders
 Affect Fluid and electrolyte balance, blood
volume, and ability to filter waste
 Pyelonephritis
 Renal Calculi
Polycystic Kidney Disease
 Multiple fluid filled cysts
(benign)
 3 types
 Autosomal dominantinherited (90%)
 30-40 year olds
 Autosomal recessiveextremely rare
 Young children
 Acquired cystic
 Patients with long tern
kidney disease
 Symptoms






Flank pain
Headaches
Hypertension
Chronic UTI
Hematuria
Cysts in kidneys and other
organs (liver)
 Leads to kidney failure
(50%) end stage renal
disease
 Treatment
 Dialysis or transplant ( if
both kidneys are affected
Diabetic Nephropathy
 Other names
 Kimmelstiel-Wilson
disease
 Diabetic
glomerulosclerosis
 Uncontrolled diabetes
 Nephrons sclerose
 Symptoms
 Thirst and edema
 Chronic renal failure
to end stage renal
disease in 2-6 years
 Treatment
 Dialysis or transplant
End-Stage Renal Disease (ESRD)
 Kidney failure
 Function at less then 10% of their normal capacity
 Final stage of many types of kidney disease
 ½ are diabetic
 Kidney filtration is no longer effective-no urine
output
 Death occurs from accumulation of waste and
fluids
 Treatment-dialysis or transplant only
Dialysis


Hemodialysis


Establish vascular access
 Insert a shunt or long dwelling catheter
in forearm


2 cannulas
 Inflow
 Outflow
A portion of the patient’s blood is
pumped from the body to dialysis
machine
 2 compartments





Incoming blood
Solution of dialysate
 Semipermiable membrane between
Blood passes over the membrane and
fluid and waste are filtered I into
dialysate
Lager substances, blood, protein are
returned to body
3 treatments per week 2-4 hours each
Peritoneal Dialysis
Continuous ambulatory peritoneal
dialysis (CAPD)
 Permanent catheter in lower peritoneal
cavity
 Dialysater infused into peritoneal cavity
 Peritoneum acts as filter

Dialysis may be treatment of choice or
temporary measure while waiting for a
kidney
Dialysis
Renal Cell Carcinoma
 Most common type of kidney cancer
 More common in men then women
 Age of 50-60
 Direct link to smoking and heredity
 Metastasizes to the lungs
 Radical nephrectomy-75% 5 year survival
rate
Congenital Nephroblastoma




Wilm’s tumor
Malignancy found in children (3-4 yrs)
90% of cases only one kidney involved
Asymptomatic until late stages
 Hypertension
 Hematuria
 Abdominal enlargement
 Nephrectomy before metastasis has 90% 5 yr
survival rate
Pathology affecting the male
reproductive system
Phimosis
 Foreskin can’t retract over the glans
 Can cause infection do to inability to clean
 Pain during erection
 Circumcision treats this condition
Hypospadias/Epispadias
 Hypospadias-urethral opening occurs on
the under side of the penis or on the
perineum (or in the vagina of a female)
 Epispadias-absence of the anterior wall of
the urethra. Opens on the dorsal side of
the penis
Benign Prostatic Hypertrophy
 Most men over the age of 50
 Prostate enlarges-can no longer expand




outwardly due to capsule, so swells into the
urethra
Urination-frequency, urgency, and urinary
retention
Rectal exam
Prostate specific antigen (PSA) to rule out
cancer
Transurethral Resection of the Prostate (TURP)
is procedure of choice
Cancer of the Prostate
 Early stages are asymptomatic
 Same obstructive symptoms a BPH
 Matastasis to bone and other organs
 Radical prostatectomy (suprapubic or retro
pubic) with pelvic lymph node dissection
 Orchiectomy, radiation, hormone therapy
 Chemotherapy is not effective
Cryptorchidism
 One or both testicles fail to descend into
the scrotum (after 1 yr)
 Can cause future infertility
 Associated with premature birth and
inguinal hernia
 Orchiopexy-fixation of testicle in normal
position
Testicular Torsion
 Twisting of the
spermaticord
 Pain and eschimia
 Temporary manual
derotation
 Orchiopexy to prevent
recurrence
 Wood’s lamp to
determine viability of
the testicle
Testicular Cancer
 Young men between 20 and 40
 Patients who had cryptorchisism are at higher




risk
Young men are too embarrassed to report so
goes to advance stages without treatment
Orchidectomy with radiation or chemotherapy
Bilateral orchiectomy-can reserve sperm
Testicular implants are available
Trauma to the Genitourinary
System
 MVA
 Abusive or forceful sexual activity
 Blunt physical contact
 Penetrating wounds
 Hemorrhage can lead to shock or
permanent impotence
Priopism
 Erection that won’t subside
 Vessels allowing blood to exit won’t open
 Decompression is necessary
 Can lead to permanent impotence
Other Male Pathology









Balanoposthitis- inflammation of glans
Prostatitis
Erectile dysfunction
Penile cancer
Epididymitis
Hydrocele
Orchitis
Varicocele
Sexually Transmitted diseases
 Genital Warts
Urinalysis
 Clean container
 Clean catch
 Disinfect
 Midstream
 Sterile
 Catheter
 24 hour sample
 Microscopic exam vs. strips
Other Tests
 History and physical
 Lab-blood and Urinalysis
 X-ray-KUB
 IVU- retrograde urogram (IVP-IV pylogram)
 Ultrasound
 CT scan
 MRI
 Biopsy
 Endoscopy
Equipment







Table for lithotomy and x-ray
X-ray equipment (give radiology notice)
X-ray gowns
Poles for irrigation fluid
Drainage system in table or floor
Sitting stool for surgeon
Supplies




Lubricant
Foley and drain bag
Catheter guide
Ureteral catheters and baskets
Incisions
 Inguinal
 Scrotal-transverse with





tension
Pfannestiel
Gibson
Flank
Lumbar
Abdominal
Surgical Procedures
Adrenalectomy
 To remove a tumor
causing
 Cushing’s Syndrome
 Pheochromocytoma
 Breast or prostate cancer
 Endoscopic or open
(large tumors or
malignancies)
 Procedure
 Flank incision
 #10 blade possible rib
instruments
 Dissection
 Pickups and scissors
 Bovie
 Cut fibrous attachments of
gland
 Pickups and scissors
 Transect artery and vein
 Clamp, clamp, cut, tie, tie
 Irrigation & hemostasis
 Asepto, bovie
 Closure
Wilms Tumor
 Transverse skin incision
 Moist sponge placed over tumor to protect it.
 Tumor spillage increases local tumor recurrence
 Umbilical vein and renal vein are ligated
 Renal arteries and adrenal arteries ligated
 Tumor , adrenal glands, ureters and
unilateral lymph nodes are removed.
 Irrigated and inspected
 Wound closure
Nephrectomy
 Total or subtotal removal
of kidney
 Subtotal-upper or lower
pole only
 biopsy, calculi, or small
cancer
 Renal cooling if artery will
be occluded for a long
period of time
 Use of iced slush
 Reduces metabolic
requirements of a kidney
 Reduces the possibility of
tubular necrosis
 Need sterile iced slush and
Collins solution
Procedure
Flank incision








 #10 blade
Dissection and mobilization of
kidney
 Pickups and scissors
Control artery
 Vessel loop or bulldog clamp
Retract renal capsule
 Pickups and scissors
Ligate segmental artery
 Clamp, clamp, cut, tie, tie
Remove segment
 #10 blade, pickups
Close capsule
Cover defect with peritoneum
or omentum
Close
Simple Nephrectomy
 Flank incision
 #10 blade, bovie
 Dissection
 Pickups and scissors
 Rib extraction inst
 Isolate and ligate the
ureter
 Pickups and scissors,
suture
 Expose and ligate the
renal artery and vein
 Pickups and scissors
 Clamp, clamp, cut, tie, tie
(0 silk)
 Remove kidney
 Hemostasis
 Close
 Removal of kidney only
 Small malignancies,
chronic obstructive
disorder, benign
tumors, transplant
kidney.
 Living donor hepranized
prior to removal
 Kidney infused with
cold collins
(perservative) solution.
Radical Nephrectomy
 Removal of kidney,
adrenal gland,
perirenal fat, upper
ureter, gerota’s fascia
 Regional lymph
nodes may be
included
 Abdominal incision
 Abd. Organs can be
inspected for
metastasis.
 Intake and output
levels are measured
for 24-48 hours
postoperatively
 Remaining kidney is
expected to handle
additional load
without difficulty if not
diseased.
Renal Transplant
 Sources
 Cadavers
 Advanced directive or family consent
 Anesthesiologist-maintains heart and lungs
 Could need to transport organ
 Collins solution and iced slush used to preserve
 Living donors
 Simple nephrectomy
 Left kidney usually used due to longer renal vein
 80% success with unrelated, 90% if related
 Compatibility-blood studies
Recipient
 Undergoes dialysis just before the procedure to






stabilize fluid and electrolyte balance
Graft is placed in the right pelvis through gibson
incision
Graft to internal iliac artery and external iliac
vein
Perfusion of kidney is allowed and observed for
proper color
Manitol will be given to increase urinary output
Anastomosis of the ureter to the bladder
Children have kidney anastomosed to the aorta
and inferior venacava (midline incision)
Transurethral Endoscopy of the
Genitourinary Tract
 Cystoscope (0, 30, 70,120
degree) or ureteroscope (rigid or
flexible)
 Patient is in lithotomy
 Introduce scope through the male
or female urethra
 Procedures








Retrograde urogram
Visual diagnosis
Bleeding tissue fulguration
Prostate tissue removal (TURP)
Removal of bladder tumors
Ureteral stents
Caliculi removal
Urethral enlargement
 Equipment sterilization
 Gas vs. steam vs. cidex
 Tech often sets up table (open
glove) then scrubs out
 No saline in graduate
 After table is setup may assist with
circulating duties
 Keep plenty of fluid hung
 Inflow and outflow should match
closely
 “A variety of urinary catheters
should be available for insertion at
the end of the procedure. The
surgeon, circulator, or Surgical
Technologist may perform this
task.” (p. 776 AST)
Stone Removal
 Spontaneous
 increase fluids, muscle relaxants, pain
medications
 Lithotripsy
 painful-general anesthetic
 Endoscope of urinary tract
 Open procedures
Lithotomy
 Open stone removal
 Position and incision depends on location
of the stone
 Pylolithotomy-stones in the kidney or
upper ureter-flank incision
 Gibson incision for stones in lower ureter
 Suprapubic or phannesteal incision for
bladder stones
Extracorporeal Shock Wave
Lithotripsy (ESWL)
 Pulverizes Calculi into small fragments for evacuation







with the urine
Kidney and upper urethral stones only
Expensive specialized equipment so some facilities
share the equipment (mobile machines)
Buttocks and torso are submerged in pool of deionizing
water
C-arm locates stone then shock waves pulverize stone.
Recheck with C-arm every 200 shocks
1000 shocks for a 4 mm stone
2,400 shocks maximum exposure for a day
Patient strains urine for stone fragments to analyze
chemical composition
Endoscopic Stone Manipulation
 Stones are accessed transurethrally
 Cystoscopy and ureteroscope (flexible or rigid)




may be needed
Glide wire or guide wire to maintain
communication of ureter from bladder to kidney
Stone baskets or laser
C-arm and retrograde dye to identify location of
stone. Get all air out of syringe-looks like a
stone.
Ureteral stent my be placed to maintain patency
of the ureter
Ureteral Reimplantation
 Pathology requiring urinary diversion.
 Ureteroneocystostomy
 Reposition the ureter on the superior portion
of the bladder.
 Ureterostomy
 Opening the ureter for continuous drainage
into another body part.
 Ureterectomy
 Complete excision of the ureter
 In conjunction with a nephrectomy
Ureteral Reimplantation
 Ureteroureterostomy
 Excision of a traumatically injured or diseased
portion of the ureter with reanastomosis to
restore continuity to the ureter.
 Ureteroenterostomy
 Ureteroileostomy (ileal urinary conduit)
 Diversion of the ureter into a segment of the ileum
 Ureterosigmoidostomy
 Diversion of the ureter into a segment of the
sigmoid.
Suprapubic Cystotomy
 Suprapubic catheter-when
transurethral approach is
impossible
 Men with enlarged prostate
 Disabled
 Percutaneous Procedure
 Shave prep and local anesthetic
 Incision
 #11 blade
 Insert cystostomy tube just above
pubis
 Remove obturator from tube
 Inflate balloon the suture or tape
in position
 Connect to collection device
 Regulate speed of evacuationsudden relief of abdominal
pressure can lead to severe drop
in blood pressure
Open Procedure
Cystectomy Ileal Conduit
Cystectomy/Ileal Conduit
 Removal of bladder and diversion through a portion of
the intestine
 Radical cystectomy-treats malignancies invading nearby
tissues
 Male
 Bladder, prostate, seminal vesicles
 Female
 Bladder, urethra, anterior vaginal wall, uterus, fallopian tubes,
ovaries
 Ileal conduit
 External appliance for collection of urine or
 Continent urinary reservoir (Koch pouch) made from
reconfigured bowel
 400-1200ml capacity
 Emptied by periodic catheterization of a stoma
Radical cystectomy with Ileal
conduit-continued
Considerations
-Major, bowel and long instrument
sets, self retaining abdominal
retractor, hemoclip appliers
-Stoma supplies, bowel staplers,
ureteral stents, ties on a pass,
kitners, and sponge sticks
-patient will have a bowel prep,
foley
-General surgeon will assist
 Procedure
 Midline abdominal incision
 #10 blade, bovie
 Expose bladder
 Moist laps and abdominal
retractor
 Scissors and pickups
 May terminate here if tumor is too
invasive
 Lymph nodes excised
 Pickups and scissors
 Frozen section
 Dissect bladder, vas, and vessels
 Bovie, hemoclips, long metz, long
DeBakeys, long clamps, ties on a
pass, sponge stick, kitners
 Clamp, clamp, cut, tie, tie
 Dissect and transect ureters
 Pick ups and scissors
 Frozen section for margins
 Procedure-continued
 Mobilize toward prostatic urethra
 care is taken to maintain erectile
capability
 Remove Foley and transect
urethra
 Large silk suture
 Remove bladder, control bleeding
 Pickups, scissors, bovie
 Pack with moist sponges
 Conduit procedure
 Divide 20 cm length of terminal
ileum
 Intestinal clamps x2
 Intestinal staplers
 Divide mesentery
 Clamp, clamp, cut, tie, tie
 Reanastomose remaining bowel
and close mesentery
 Bowel staplers, long silk suture
 Implant ureters into segment of
ileum
 Knife, suture of surgeon’s choice
 Stents
 Distal end of conduit makes stoma
 Skin knife, army-navys, suture
 Close incision
 Dressings and stoma bag
Marshall-Marchetti-Krantz
 Bladder suspension
 Also called a Birch
 Women with significant urinary
stress incontinence
 Post childbirth or aging
 Elevates bladder base, reduces
redundant vaginal tissue, and
fixes urethral angle
 Gynecologist-with vaginal or
abdominal hysterectomy
 Procedure
 Phannenstiel incision
 #10 blade, bovie
 Blunt dissection of bladder and
urethra
 Sponge stick, lap
 Metzenbaum, dressing forceps
 Assistant inserts 2 gloved fingers
into vagina to elevate bladder
 Gloves, sleeve, towel around
opening
 Bandage scissors to cut drape
 4 heavy sutures are placed in the
anterior vaginal wall by urethra
and secured to pubis symphisis or
Coopers ligament
 Haney needle holders, kellys to
tag suture (leave untied and
uncut)
 Tie suture sequentially then cut for
optimal tension
 Close-may pack vagina
Stamey
 Endoscopic attachment of bladder neck to rectus fascia






using stamey needles
Suture placement verified with cystoscope
Done in conjunction with vaginal hysterectomy often
2 small super pubic incisions for stamey needles where
suture is tied
Each time scope is removed insert Foley catheter
Sutures are tied sequentially for equal tension then cut
Close small wounds
Stamey
Stamey-continued
Circumcision
 Removal of the prepuce
 Newborns at parents
request for religious or
personal reasons or to
repair phimosis
 Performed in the delivery
room, newborn nursery,
or physician’s office
 Minimal prep
 Bell Procedure
 Bell shaped device is
placed over glans
 Foreskin is pulled taught
over the bell
 Second part of bell device
is place over the foreskin
and tightened.
 Bell cuts off blood supply to
prepuce and guides 15
blade as surgeon cuts
 Remove clamp and suture
if necessary
 Callodian dressing or
nonadherent dressing is
used.
Circumcision
 Procedure (no bell)
 Straight hemostat on
posterior midline of foreskin
several minutes to cut off
blood supply
 Remove clamp and cut
dorsal slit (15 blade)
 Circumferential freehand
incision around shaft
 Raw edges are sewn
together leaving glans
exposed
 Nonadhearent dressing
Orchiectomy/Orchiopexy
 Orchiectomy-removal of
 Orchiopexy-fixation of
one or both testicles
 Radical-for testicular
cancer
one or both testicles in
the scrotal sac
 Repairs
 Entire contents of
hemiscrotum, tunica
vaginalis, spermatic cord
 Inguinal incision
 Simple-abscess or
prostate cancer
 Testis and epididymis
 Scrotal incision
 Testicular torsion
 Undescended testicle
 Scrotal incision
 Done bilaterally even if
only one side is affected
Orchiectomy Procedure
 Scrotal incision
 #15 blade, tension on
scrotum
 Testis and spermatic cord
are extruded through the
wound
 Cord structures are
separated and identified
 Metzenbaum and pickups
 Ligate cord structures
 Clamp, clamp, cut, tie, tie
 Testicular implant if
desired
 Close
Orchiopexy
 Scrotal incision
 #15 blade, tension on
scrotum
 Enter tunica vaginalis
 Pickups and scissors
 Position testicle in
scrotum
 Suture tunica albuginea
to dartos muscle-2 lateral,
one inferior
 Nonabsorbable suture
 Close
 Repeat on other side
Hydrocelectomy
 Accumulation of fluid in tunica vaginalis due to trauma or
infection
 Procedure
 Scrotal incision
 #15 blade
 Dissection to vaginalis
 Tenotomy scissors, Adson's with teeth
 Fluid is evacuated
 Scissors, Adson's, suction
 Excess tunica is excised
 Adson's and tenotomy scissors
 Close tunica and scrotum
 Dressing
 Fluffs and jockstrap
Vericocelectomy
 Dilation of spermatic
veins
 Blood pools and warms
scrotal contents
 Can kill sperm reducing
fertility
 Pain and swelling of
scrotum
 Left side most common
 Can be done




Open inguinal incision
Microsurgery
Laparoscope
embolization
 Procedure
 Inguinal incision
 #10 blade, bovie
 Vein dissection
 Metzenbaum and pickups
 Ligate vein
 Clamp, clamp, cut, tie, tie
 Close
Hypospadias Repair




Usually done between ages 1-4
Done in 1 or 2 stages depending on difficulty
Involves a glanuplasty, orthoplasty and urethroplasty
Procedure
 Circumferential incision
 #15 blade
 Dissection of skin
 Pickups and scissors
 Close meatus
 Small suture
 Chordee repair
 Cut fibrous bands along entire penis
 Skin graft for urethral repair if needed
 Skin from penis wrapped around foley
 Small suture
 Close skin
Insertion of Penile Prosthesis
 Treatment of male impotence
 Prosthesis
 Inflatable
 Semi rigid
 Place a foley to identify location of
urethra
 Procedure
 Incision-base of penis to scrotum
 #15 blade
 Incise tunica albuginea of both
corpora
 #15 blade
 Traction sutures
 1 Silk
 Dilate corpora
 Hegar dilators
 Furlow inserter is used to
measure length
 Advance prosthesis on both sides
 Keith needles through glans
 Place pump in scrotum following
inguinal canal
 Fill reservoir with fluid
 Connect rods and reservoir
 Test
 Close
Vasectomy
 To produce permanent
sterility
 Usually done in doctor’s
office
 Sterility is not immediate
 15 ejaculations to remove
residual sperm
 Reanastomosis occurs in
less then 1% of cases
 Procedure
 Local
 Incision
 #15 blade
 Vas is isolated above the
epididymis
 Penetrating towel clamp
 Wide ligation
 Clamp, clamp, cut, tie, tie
 Remove segment
 Fulgurate ends of
remaining vas
 Bovie
 Close
Vasectomy
Vasovasotomy




Vasectomy reversal
Microscope or loupes
Bilateral
No intercourse for 1
month
 Semen analysis
 50% conception rate
 Procedure
 Scrotal Incision
 #15 blade
 Excise scar tissue
 Micro scissors ad forceps
 Dilate lumens
 Anastimose ends of vas
 Micro suture, Castroviejo
needle holders, pickups,
scissors
 May stent
 Close scrotum
Prostatectomy
 Instruments and supplies









Major instruments
Large retractor
Long instruments
Hemoclip appliers
Bovie extender
Foley
KY jelly
Suprapubic catheter
IV indigo carmine is used to locate
the ureters
 3 methods
 Suprapubic-through bladder
 Retropubic-avoids bladder
 Perineal-potential of impotence
and rectal injury
 Procedure
 Pfannenstiel incision
 #10 blade
 Dissect bladder from peritoneum
 Kitners, sponge stick
 Enter bladder
 “Deep” knife
 Remove foley and incise base of
bladder
 Long handle #10 blade
 Blunt dissection of prostate
 Tumor is removed via bladder
 Hemostasis
 Suture, tie on a pass, bovie,
hemoclips
 Reinsert foley
 Close bladder
 Drain and close skin
Prostatectomy
TURP
 Transuretheral Resection of the Prostate
 Watch for pt. jerking
 Electrical stimulation to nerves
 Hemoorhage
 Ready to move to open
 Perforation
 TURP syndrome
TURP